[0001] FIELD OF THE INVENTION
[0002] The present invention relates to pharmaceutical compositions for treatment of diseases
of the eye characterized by undesired or abnormal choroidal neovascularization, particularly
age-related macular degeneration (AMD). In particular, the invention relates to the
use of pharmaceutical compositions comprising complement inhibitor proteins, in particular
a soluble complement receptor type I (sCR1), which have been found to be useful in
the treatment of AMD in a relevant animal model.
[0003] BACKGROUND OF THE INVENTION
[0005] AMD is a complex disease whose risk factors include aging, family history of AMD,
smoking, hypertension, obesity, diet, and ethnicity, and there is a strong indication
of a genetic contribution.
Ambati et al., Surv. Ophalmol., 48:257 (2003). Two major clinical phenotypes of AMD are recognized: a nonexudative (dry) type
and an exudative (wet) type.
[0006] The dry form of AMD is associated with cell death of the light-sensitive macular
part of the retina, which is required for fine vision used in activities such as reading,
driving or recognizing faces. Over time, as less of the macula functions, central
vision in the affected eye can be lost gradually. One of the most common early signs
of dry AMD is the appearance of drusen. Drusen are yellow deposits under the retina
and are often found in people over the age of 60. Dry AMD has three stages, all of
which may occur in one or both eyes: early AMD, intermediate AMD, and advanced AMD.
Early and intermediate AMD are characterized by the presence of small or medium-sized
drusen, and persons suffering from early and intermediate AMD may require additional
light when reading and experience a blurred spot in the center of their vision. Persons
suffering from advanced AMD, in addition to the presence of medium or large-sized
drusen, exhibit a breakdown of light-sensitive cells and supporting tissue in the
central retinal area.
[0007] The wet form of AMD is caused by growth of abnormal blood vessels, also known as
choroidal neovascularization (CNV), under the macula. These vessels leak blood and
fluid which raises the macula from its normal position at the back of the eye and
causes scar tissue formation, which destroys the central retina and results in deterioration
of sight. The pathogenesis of new choroidal blood vessel formation which characterizes
wet AMD is not completely understood. Inflammation, ischemia, and local production
of angiogenic factors are all thought to be important in pathogenesis. With wet AMD,
loss of central vision can occur quickly. Wet AMD is considered to be advanced AMD
and is more severe than the dry form.
[0009] Although the direct cause of AMD remains unknown, recent studies have pointed to
a number of single nucleotide polymorphisms (SNPs) in and around the gene for complement
Factor H which appear to predispose people to AMD. Patients exhibiting this mutation
have been linked to an increased likelihood of developing the disease. See,
Hageman et al., 2005, PNAS, 102(20): 7227-7232;
Klein et al., 2005, Science, 308: 385-388;
Haines et al., 2005, Science, 308: 419-421. See, also,
Edwards, 2005, Science, 308: 421;
Li, 2006, Nature Genetics, 38: 1049;
Despriet, 2006, JAMA, 296: 301;
Maller, 2006, Nature Genetics, 38: 1005.
[0010] Factor H is one of the complement regulatory proteins which down-regulates complement
activation and is a member of the family of genes known as the Regulators of Complement
Activation (RCA) gene locus encoded on human chromosome 1q32. The complement system
is a group of proteins that constitutes about 10 percent of the globulins in normal
serum of humans (
Hood et al., Immunology, 2d Ed. (The Benjamin/Cummings Publishing Co., Menlo Park,
Calif., 1984), p. 339), and it plays an important role in the mediation of immune and allergic reactions.
The complement system is a major component of innate immunity and is a central host
defense against infection. The activation of complement components leads to the generation
of a group of factors, including chemotactic peptides that mediate the inflammation
associated with complement-dependent diseases.
[0011] Activation of the complement cascade may occur via the classical pathway, involving
antigen-antibody complexes, by the lectin pathway, or by the alternative pathway,
involving the recognition of certain cell wall polysaccharides. The activities mediated
by activated complement proteins include lysis of microorganisms, chemotaxis, opsonization,
stimulation of vascular and other smooth muscle cells, degranulation of mast cells,
increased permeability of small blood vessels, directed migration of leukocytes, and
activation of B lymphocytes and macrophages. The membrane attack complex (MAC) is
the final product of the activated complement cascade. It is a lytic multi-protein
complex that is lethal to pathogens and, at sublytic levels, causes the release of
cytokines and growth factors such as beta-FGF and VEGF from nucleated cells (e.g.,
smooth muscle cells, endothelial cells).
[0012] Factor H is one of a dozen or so proteins of the complement system having a repeating
structural motif known as a short consensus repeat (SCR) and sharing a capacity for
interacting with activation products of the complement components C3 and C4, as well
as other components of the complement system.
Ahearn et al., 1989, Adv. Immunol., 46:183-219. During complement activation, biologically active peptide fragments, the anaphylatoxins
C3a, C4a, and C5a, are released from complement components C3, C4, and C5.
Hugli, 1981, CRC Crit. Rev. Immunol., 1:321. Factor H and other complement regulatory proteins such as C4-binding protein (C4-BP),
decay accelerating factor (DAF), membrane cofactor protein (MCP), and complement receptor
type I (CR1) have a negative regulatory activity and are able to block one or both
of the complement activation pathways.
[0013] Current treatments for AMD are limited. No treatment for advanced dry AMD exists.
However, the transition from intermediate AMD to advanced AMD can be delayed and possibly
prevented by taking a specific high-dose formulation of antioxidants and zinc. Research
has shown that a daily intake of supplements, including: vitamin C (500 milligrams);
vitamin E 400 IU; beta-carotene (15 milligrams); zinc (as zinc oxide) (80 milligrams);
and copper (as cupric oxide) (2 milligrams), reduced the risk of patients advancing
from intermediate AMD to advanced AMD by 25%, and reduced the risk of vision loss
by 19%. (www.amd.org).
[0014] Currently there are only four treatments approved by the FDA for wet AMD: laser surgery,
photodynamic therapy (PDT), and the drugs Macugen® pegaptanib sodium and Lucentis™
ranibizumab intravitreal injections. Laser, PDT and pegaptanib may slow the rate of
vision decline and/or stop vision loss. Pegaptanib (Macugen®, Eyetech Pharmaceuticals
Inc. and Pfizer Inc.), is approved for treatment of wet AMD is a pegylated oligonucleotide
aptamer targeting VEGF. Ranibizumab (Lucentis™, Genentech/Novartis), an antibody fragment
targeting VEGF, has recently been approved by FDA for the treatment of wet AMD.
[0015] Laser surgery attempts to destroy the fragile, leaky blood vessels using a high energy
beam of light. This treatment, however, may also destroy some surrounding healthy
tissue and therefore actually contribute to further vision loss. Because of this,
only a small percentage of people with wet AMD can be treated with laser surgery.
[0016] Photodynamic therapy also attempts to destroy the newly formed blood vessels in the
patient's eye. Verteporfin (marketed in the US by Novartis under the name Visudyne®)
is injected into the patient's arm. The drug travels through the patient's body, "sticking"
to the surface of new blood vessels. A light is then shone in the patient's eye, which
activates the drug, which in turn destroys the new blood vessel. Photodynamic therapy
merely temporarily slows the rate of vision loss; it does not stop vision loss or
restore vision. Moreover, because the drug is activated by light, the patient must
avoid sunlight and bright indoor lights for five days after treatment.
[0017] Genetic research continues to illuminate more treatment options. For example, in
a study released in September 1997, scientists reported that 16% of 167 patients with
dry AMD had a defect in a gene called ABCR. See,
Allikmets et al., 1997, Science, 277(5333): 1805-7. However, the fact that 84% of the patients suffering from dry AMD in the study did
not have the ABCR gene defect indicates that further research is needed. Other family-based
whole-genome linkage scans have identified chromosomal regions that show evidence
of linkage to AMD; however, the linkage areas have not been resolved to any causative
mutations. See,
Klein et al., 2005, Science, 308: 385-388.
[0018] While the recent studies linking a mutation in a complement regulatory protein (Factor
H) to development of AMD (see, Hageman et al., 2005,
supra; Klein et al., 2005,
supra; Haines et al., 2005,
supra; Edwards et al., 2005,
supra) raises the question of whether the function of Factor H in regulating complement
activation is one factor that might play a role in AMD, there is as yet no evidence
that therapeutic administration of complement proteins has any impact on AMD. No treatment
or therapy utilizing components of the complement system has been proposed.
[0019] Clearly, needs remain for an effective treatment of age-related macular degeneration
and like diseases of the eye characterized by undesired or abnormal neovascularization.
[0020] SUMMARY OF THE INVENTION
[0021] The present invention relates to the use of a complement inhibitory protein for the
therapeutic treatment of diseases involving choroidal neovascularization, and in particular,
age-related macular degeneration (AMD). More particularly, the invention is directed
to the administration of soluble complement receptor type I (sCR1) by intravitreal
or systemic administration.
[0022] Thus, the present invention provides soluble complement receptor type 1 (sCR1) protein
for use according to claim 1. The present invention also provides use of a sCR1 protein
for the manufacture of a medicament according to claim 8. There is also disclosed
an intraocular formulation comprising an amount of a complement inhibitory protein,
and more particularly a soluble CR1 protein, effective to inhibit complement and a
pharmaceutically acceptable vehicle.
[0023] Also disclosed is a method for treating AMD comprising intraocular administration
of an amount of a complement inhibitory protein effective to inhibit complement activity
to a mammalian subject suffering from AMD or susceptible to AMD. Administration of
the complement inhibitory protein can advantageously be intraocular (IO), including
intravitreal (IVT).
[0024] Also disclosed is a method for treating AMD comprising systemic administration of
an amount of a complement inhibitory protein effective to inhibit complement activity
to a mammalian subject suffering from AMD or susceptible to AMD. Administration of
the complement inhibitory protein may be intravenous (IV), subcutaneous (SC), intramuscular
(IM), intra-arterial, intraperitoneal (IP), intrathecal, pulmonary, or oral.
[0025] The invention provides for the therapeutic treatment of eye diseases or disorders
characterized by choroidal neovascularization, in particular age-related macular degeneration
(AMD) but also other eye disorders having shared physiological indicia, such as histoplasmosis,
myoptic maculopathy, idiopathic CNV, diabetic retinopathy and Purtscher's retinopathy,
etc.
[0026] BRIEF DESCRIPTION OF THE DRAWINGS
[0027] Figure 1 is a graph showing the choroidal neovascularization thickness (µm) of representative
sections of the choroidal burn sites of the test animals.
[0028] Figure 2 shows histopathologic slides exemplifying the choroidal neovascularization
in a test animal treated with sCR1 and in a vehicle-treated (negative control) subject.
These slides show the characteristic lesions and choroidal neovascularization of the
CNV model.
[0029] Figure 3 are histopathologic slides comparing the retinal neovascularization in test
animals treated with sCR1 vs. positive (Triamcinolone) and negative (vehicle) controls.
The first panel shows results from a subject treated with vehicle only (negative control)
(hematoxylin and eosin stain, magnification 400X): it is seen that retinal neovascular
plaque formation is thicker and more extensive than that seen in samples from treated
subjects. The second panel shows results from a subject treated with vehicle only
(negative control) (hematoxylin and eosin stain, magnification 100X): it is seen that
retinal neovascular plaque formation is thicker and more extensive than that seen
in samples from treated subjects. The third panel shows results from a subject treated
with sCR1 (hematoxylin and eosin stain, magnification 100X): it is seen that retinal
neovascular plaque formation is thinner an not so extensive than that seen in samples
from untreated subjects. The fourth panel shows results from a subject treated with
Triamcinolone (hematoxylin and eosin stain, magnification 200X): it is seen that retinal
neovascular plaque formation is thinner an not so extensive than that seen in samples
from untreated subjects.
[0030] DETAILED DESCRIPTION
[0031] The present invention is based on the important and surprising discovery that administration
of the complement inhibitory protein soluble CR1 is effective in reducing undesired
neovascularization in the eye in a relevant animal model of AMD.
[0032] In order that the invention may be more fully understood, the following terms are
defined.
[0033] The term "complement inhibitory protein" as used herein refers to any of the complement
regulatory proteins that have a negative regulatory activity on complement activation.
Complement inhibitory proteins useful in the present invention include, specifically,
soluble complement receptor type I (sCR1), C4-binding protein (C4-BP), decay accelerating
factor (DAF), membrane cofactor protein (MCP), and Factor H. Soluble CR1 polypeptides
having at least the C3b and C4b binding sites intact are preferred, as such molecules
have the ability to block complement activation via the classical activation pathway
and the alternative activation pathway both. Reference to specific complement inhibitory
proteins includes fragments of such proteins produced by truncation or splicing-out
of unwanted polypeptide segments, so long as complement regulatory activity is retained.
Derivatives made by one or more amino acid substitutions or linking to other structures
such as carrier proteins or immunoglobulin constant regions are also contemplated,
again so long as complement inhibitory activity is retained. In particular, soluble
CR1 polypeptides having at least one of the C3b or C4b binding sites intact are preferred,
because such molecules will retain the ability to block complement activation via
the alternative complement pathway.
[0034] As used herein, the terms "soluble complement receptor type I", "soluble CR1 polypeptides"
or "soluble CR1" or "sCR1" will be used to refer to portions of full-length human
CR1 protein which, in contrast to the native CR1 proteins, are not expressed on the
cell surface as transmembrane proteins but nevertheless exhibit a complement regulatory
activity such as C3b binding, C4b binding, the ability to inhibit the classical complement
activation pathway and/or the alternative complement activation pathway, and/or the
lectin complement activation pathway, etc. In particular, CR1 polypeptides which substantially
lack a transmembrane region, or, preferably, which comprise all or part of the extracellular
domain of CR1 and retain a complement regulatory activity, are soluble CR1 polypeptides.
In a preferred embodiment, the soluble CR1 polypeptides useful in the present invention
are secreted by a cell in which they are expressed. Suitable soluble CR1 polypeptides
and preparations are described in detail, e.g., in
U.S. Pat. No. 5,981,481;
U.S. Pat. No. 5,456,909; and
U.S. Pat. No. 6,193,979. Special mention is made of a soluble CR1 polypeptide having glycosylation modified
to exhibit sialyl Lewis X moieties. (sCR1-sLe
x), as described in
U.S. Pat. No. 6,193,979; novel glycoform preparations of soluble CR1 having an increased
in vivo half-life described in
U.S. Pat. No. 5,456,909; and soluble constructs having two or more CR1 moieties linked to a carrier molecule,
e.g., an sCR1-F(ab)2 fusion, as described in
U.S. Pat. No. 6,458,360. Also contemplated are soluble CR1 polypeptides having at least one of the C3b or
C4b binding sites intact covalently linked to lipopeptides to facilitate localization
on cell surfaces, as disclosed in
U.S. Pat. No. 6,713,606. More preferably, the invention utilizes a polypeptide comprising the extracellular
domain of mature human CR1 (SEQ ID NO:1).
[0035] As used herein, the terms "treatment" or "treating" refers to any regimen that alleviates
one or more symptoms of a disease or disorder, that inhibits progression of a disease
or disorder, that arrests progression or reverses progression (causes regression)
of a disease or disorder, or that prevents onset of a disease or disorder. Treatment
includes prophylaxis and includes but does not require cure of a disease or disorder.
[0036] Macular degeneration is a clinical term that is used to describe a variety of diseases
that are all characterized by a progressive loss of central vision associated with
abnormalities of Bruch's membrane, the neural retina and the retinal pigment epithelium
(RPE). These disorders include very common conditions that affect older patients (age-related
macular degeneration or AMD) as well as rarer, earlier-onset dystrophies that in some
cases can be detected in the first decade of life (
Best, 1905, Z. Augenheilkd., 13:199-212). The term "macular degeneration" as used herein refers to any of a number of conditions
in which the retinal macula degenerates or becomes dysfunctional, e.g., as a consequence
of decreased growth of cells of the macula, increased death or rearrangement of the
cells of the macula (e.g., RPE cells, loss of normal biological function, or a combination
of these events). Macular degeneration results in the loss of integrity of the histoarchitecture
of the cells of the normal macula and/or the loss of function of the cells of the
macula. Any condition which alters or damages the integrity or function of the macula
(e.g., damage to the RPE or Bruch's membrane) may be considered to fall within the
definition of macular degeneration. Other examples of diseases in which cellular degeneration
has been implicated include retinal detachment, chorioretinal degenerations, retinal
degenerations, photoreceptor degenerations, RPE degenerations, mucopolysaccharidoses,
rod-cone dystrophies, cone-rod dystrophies and cone degenerations.
[0037] As used herein, the terms "disease" and "disorder" have the meaning generally known
and understood in the art and comprise any abnormal condition in the function or well
being of a host individual. A diagnosis of a particular disease or disorder, such
macular degeneration and more specifically, age-related macular degeneration, by a
healthcare professional may be made by direct examination and/or consideration of
results of one or more diagnostic tests. The term "disease of the eye characterized
by undesired neovascularization" refers to any disease or disorder in which neovascularization
causes or contributes to damage to the eye or a particular structure of the eye (e.g.,
retina, macula, rods, cones, retinal pigment epithelium, Bruch's membrane, etc.) or
causes or contributes to impairment of vision from the eye. Diseases and disorders
contemplated by this term include but are not limited to wet AMD, diabetic retinopathy,
corneal neovascularization, choroidal neovascularization, cyclitis, Hippel-Lindau
Disease, retinopathy of prematurity, pterygium, histoplasmosis, iris neovascularization,
macular edema, glaucoma-associated neovascularization, Purtscher's retinopathy, and
the like. Although dry AMD is not primarily characterized by neovascularization, the
fact that patients who develop the wet form of AMD are believed to have had the dry
form of AMD first, leads us to believe that the treatments described herein will be
beneficial in the treatment of dry AMD, e.g., to arrest or slow its progress, and
that dry AMD may be included in this disease category.
[0038] A composition or method described herein as "comprising" one or more named elements
or steps is open-ended meaning that the named elements or steps are essential, but
other elements or steps may be added within the scope of the composition or method.
To avoid prolixity, it is also understood that any composition or method described
as "comprising" (or "comprises") one or more named elements or steps also describes
the corresponding, more limited, composition or method "consisting essentially of"
(or "consists essentially of") the same named elements or steps, meaning that the
composition or method includes the named essential elements or steps and may also
include additional elements or steps that do not materially affect the basic and novel
characteristic(s) of the composition or method. It is also understood that any composition
or method described herein as "comprising" or "consisting essentially of" one or more
named elements or steps also describes the corresponding, more limited, and close-ended
composition or method "consisting of" (or "consists of") the named elements or steps
to the exclusion of any other unnamed element or step. In any composition or method
disclosed herein, known or disclosed equivalents of any named essential element or
step may be substituted for that element or step.
[0039] The definitions of other terms used herein are those understood and used by persons
skilled in the art and/or will be evident to persons skilled in the art from their
usage in the text.
[0040] The method can be practiced by using any complement inhibitory protein which is effective
to block complement activation. Such complement inhibitory proteins include, for example,
complement receptor type I (CR1), factor H, C4-binding protein (C4-BP), membrane cofactor
protein (MCP), decay accelerating factor (DAF), or fragments thereof that retain complement
inhibiting properties, such as the ability to inhibit complement activation, to bind
C3b, to bind C4b, or to bind both C3b and C4b. Preferably, the complement inhibitory
protein used herein is a soluble (non-membrane-bound) form of human CR1. Suitable
soluble CR1 polypeptides and preparations are described in detail, e.g., in
U.S. Pat. No. 5,981,481;
U.S. Pat. No. 5,456,909; and
U.S. Pat. No. 6,193,979.
[0041] As discussed more fully below, it has been demonstrated herein that administration
of sCR1 alleviates the effects of undesirable neovascularization, specifically in
a model commonly used to assess agents useful in treating age-related macular degeneration.
We have thus discovered that administration of a complement inhibitory protein to
a subject in a relevant AMD model reduces and/or ameliorates the pathogenesis of new
choroidal blood vessel formation believed to be caused or supported by complement
activation.
[0042] In a specific embodiment, the invention relates to soluble CR1 polypeptides and their
use for the treatment of AMD.
[0043] The human C3b/C4b receptor, termed complement receptor type I (CR1) or CD35, is naturally
present on the membranes of erythrocytes, monocytes/macrophages, granulocytes, B cells,
some T cells, splenic follicular dendritic cells, and glomerular podocytes. (
Fearon, 1980, J. Exp. Med., 152: 20,
Wilson, J.G., et al., 1983, J. Immunol., 131: 684). CR1 specifically binds C3b, C4b, and iC3b.
[0044] CR1 can inhibit the classical and alternative pathway C3/C5 convertases and act as
a cofactor for the cleavage of C3b and C4b by factor I, indicating that CR1 also has
complement regulatory functions in addition to serving as a receptor. (
Fearon, D.T., 1979, Proc. Natl. Acad. Sci. U.S.A., 76: 5867;
Iida, K. I. and Nussenzweig, V., 1981, J. Exp. Med., 153: 1138.) In the alternative pathway of complement activation, the bimolecular complex C3b-Bb
is a C3 protease (convertase). CR1 can bind to C3b thereby promoting the dissociation
of fragment Bb from the complex. In the alternative pathway of complement activation,
the tri-molecular complex C3b-C3b-Bb is a C5 protease (convertase). CR1 can bind to
C3b-C3b thereby promoting the dissociation of fragment Bb from the complex. Furthermore,
binding of C3b to CR1 renders C3b susceptible to irreversible proteolytic inactivation
by factor I, resulting in the production of inactivated derivatives of C3b (namely,
iC3b, C3d and C3dg). In the classical pathway of complement activation, the bimolecular
complex C4bC2a is the C3 convertase. CR1 binds to C4b thereby promoting the dissociation
of C2a from the complex. In the classical pathway of complement activation, the complex
C3bC4bC2a is the C5 convertase. CR1 binds to C4b and/or C3b thereby promoting the
dissociation of C2a from the complex. The binding renders C4b and/or C3b susceptible
to irreversible proteolytic inactivation by factor I. Finally, the lectin pathway
(also called the mannose binding lectin or MBL pathway) feeds into the classical pathway
upstream of the C3 convertase. Thus, CR1 inhibits lectin pathway activation through
its inhibitory activities on the classical pathway at the C3 and C5 activation steps.
[0045] Factor H has some of the same properties exhibited by CR1 but is not effective to
block both activation pathways. Factor H has decay accelerating activity and Factor
I cofactor activity in the alternative pathway only. In addition, the activity of
Factor H is restricted to non-activating surfaces. This is an important distinction
with respect to CR1, which is active both on activating and non-activating surfaces
and is therefore more suitable for use under conditions of an ongoing disease. Activating
surfaces would include, e.g., the presence of drusen as well as necrotic and inflamed
tissue.
[0046] Several soluble (non-membrane bound) fragments of CR1 have been generated via recombinant
DNA procedures by eliminating the transmembrane and cytoplasmic regions from the DNAs
being expressed. See, e.g.,
Fearon et al., Intl. Patent Publn. WO 89/09220, Oct. 5, 1989. The soluble CR1 fragments are functionally active, i.e., retaining the ability to
bind C3b and/or C4b, inhibiting complement activation, and demonstrating factor I
cofactor activity, depending upon the native CR1 regions the CR1 fragments contain.
Such constructs inhibit
in vitro the consequences of complement activation such as neutrophil oxidative burst, complement
mediated hemolysis, C3a and C5a production, and the production of C5b-9 (MAC). A soluble
construct, sCR1/pBSCR1c, also has demonstrated
in vivo activity in a reversed passive Arthus reaction (
Yeh et al., 1991, J. Immunol., 146:250), suppressed post-ischemic myocardial inflammation and necrosis (
Weisman et al., 1990, Science, 249: 146-151) and extended survival rates following transplantation (
Pruitt et al., 1991, J. Surg. Res., 50: 350;
Pruitt et al., 1991, Transplantation, 52: 868).
[0047] The complete cDNA coding sequence and amino acid sequence of the human CR1 protein
is described in
U.S. Pat. No. 5,981,481. The isolation of the full-length CR1 gene, expression and purification of the full-length
protein and active fragments thereof, and demonstration of activity in the full-length
protein and fragments derived from the full-length protein, are described in
U.S. Pat. No. 5,981,481. The complete cDNA coding sequence of the human CR1 protein is shown in SEQ ID NO:1.
The amino acid sequence of mature human CR1 is shown in SEQ ID NO:2.
[0048] The complement inhibitory protein sCR1 that is useful in the present invention is
advantageously produced in quantity using recombinant DNA technology to express the
protein in a host cell, such as bacterial cells, mammalian cells, or even plant cells.
For the complement inhibitory protein contemplated herein, mammalian host cells, such
as Chinese Hamster ovary (CHO) cells, African Green Monkey kidney (COS) cells, or
human cells, retina-derived cells (e.g., PER.C6 cells) being preferred. Yeast expression,
E. coli expression, baculovirus expression, and plant expression are specifically contemplated,
as it is believed that non-mammalian glycosylation patterns will not have a significant
impact on biological function or pharmacokinetics in the eye. Other expression systems
for the production of recombinant proteins will also be useful for the production
of complement inhibitory proteins contemplated herein. The isolated gene encoding
the desired protein can be inserted into an appropriate cloning vector. A large number
of vector-host systems known in the art may be used. Possible vectors include, but
are not limited to, plasmids or modified viruses. The vector system must be compatible
with the host cell used. Such vectors include, but are not limited to, bacteriophages
such as lambda derivatives, or plasmids such as pBR322, pUC or CDM8 plasmids (
Seed, 1987, Nature, 329: 840-842) or derivatives of those well-known vectors. Recombinant molecules can be introduced
into host cells via transformation, transfection, infection, electroporation, etc.
[0049] Recombinant cells producing a preferred form of sCR1 are deposited with the American
Type Culture Collection, Rockville, MD (accession no. CRL 10052). The deposited cells
are a Chinese Hamster ovary cell line DUX B11 carrying plasmid pBSCR1c/pTCSgpt clone
35.6, encoding a soluble CR1 having the amino acid sequence of SEQ ID NO:3. Such sCR1
protein in purified form is produced under the product designation TP 10 by AVANT
Immunotherapeutics, Inc. (Needham, MA).
[0050] After expression in a host cell, the soluble CR1 molecules may be isolated and purified
by standard methods including chromatography (e.g., ion exchange, affinity, and sizing
column chromatography, high pressure liquid chromatography), centrifugation, differential
solubility, or by any other standard technique for the purification of proteins. Preferred
purification methods are described in
U.S. Pat. No. 6,316,604,
U.S. Pat. No. 5,252,216, and
U.S. Pat. No. 5,840,858.
[0051] Soluble CR1 proteins are therapeutically useful in the modulation of complement-mediated
diseases, that is, diseases or conditions characterized by inappropriate or undesired
complement activation. A soluble CR1 protein or fragment which can bind C3b or C4b,
and/or retain the ability to inhibit the alternative or classical C3 or C5 convertases,
and/or retain factor I cofactor activity, can be used to inhibit complement activation.
In the present invention, we have demonstrated that soluble CR1 can be used to ameliorate
or inhibit undesirable complement activity in the pathogenesis of new choroidal blood
vessel formation and macular degeneration.
[0052] In the invention, soluble CR1, is administered, preferably intravitreally, to a subject
who suffers from a disease of the eye characterized by undesired neovascularization
in order to attenuate complement activation and its role in the pathogenesis of new
choroidal blood vessel formation and macular degeneration.
[0053] In treating AMD according to the invention, a therapeutically active amount of a
complement inhibitory protein or preparation thereof is administered to a mammalian
subject in need of such treatment. The preferred subject is a human. The amount administered
should be sufficient to inhibit complement activation or inhibit the pathogenesis
of new choroidal blood vessel formation and macular degeneration. The determination
of a therapeutically effective dose is within the capability of practitioners in this
art, however, as an example, in embodiments of the method described herein utilizing
systemic administration of sCR1 for the treatment of AMD, an effective human dose
will be in the range of 0.01-100 mg/kg; preferably 0.1-10 mg/kg, most preferably 1-10
mg/kg patient body weight, depending on the route of administration. For embodiments
of the method described herein utilizing local, intraocular administration of sCR1
for the treatment of AMD, an effective human dose will be in the range of 5-10,000
µg/eye, preferably 50-5,000 µg/eye, most preferably 100-1000 µg/eye. Repeated systemic
and/or intraocular doses are contemplated in order to maintain an effective level,
e.g., to attenuate or inhibit complement activation, in a patient's system or within
the patient's eye(s), depending on the mode of administration adopted. For intraocular
administration, the volume of the dosage will be a factor, since the intraocular space
is limited and extremely sensitive to pressure.
[0054] Soluble CR1 or other complement inhibitory proteins may be used in combination or
alternating with the administration of other therapeutics prescribed for treatment
of ocular discorders involving abnormal neovascularization, especially those therapeutics
having different mechanisms of action, such as anti-angiogenic agents.
[0055] For administration, the sCR1 or other therapeutic protein may be formulated into
an appropriate pharmaceutical composition. Such a composition typically contains a
therapeutically active amount of the sCR1 or other protein and a pharmaceutically
acceptable excipient or carrier such as saline, buffered saline, salt solutions (e.g.,
BSS®), phosphate buffers, dextrose, or sterile water. Compositions may also comprise
specific stabilizing agents such as sugars, including mannose and mannitol.
[0056] Various delivery systems are known and can be used for delivery of complement inhibitory
proteins such as sCR1 polypeptides in accordance with this invention, e.g., encapsulation
in liposomes, microparticles, or microcapsules. Suitable modes of administration include
but are not limited to, intravitreal (intravitreous), intraocular, intradermal, intramuscular,
intraperitoneal, intravenous, subcutaneous, intrathecal, or epidural injection, and
oral or pulmonary delivery. A syringe such as a tuberculin syringe (i.e., a small
gauge needle on a syringe designed to deliver a small volume accurately, with a low
amount of "dead space") is preferred for intravitreal administration.
[0057] Pharmaceutical compositions containing one or more complement inhibitory proteins
for use in the present invention may be formulated in accordance with routine procedures
as a pharmaceutical composition for systemic administration to an individual suffering
from macular degeneration or any related disorder of the eye. Typically compositions
for systemic administration are solutions in sterile aqueous buffer. Where necessary,
the composition may also include a solubilizing agent and a local anesthetic such
as lidocaine to ease pain at the site of injection. Generally, the ingredients will
be supplied either separately or mixed together in unit dosage form, for example,
as a dry lyophilized powder or water free concentrate in a hermetically sealed container
such as an ampoule or sachette indicating the quantity of active agent in activity
units. Where the composition is to be administered by injection, an ampoule of sterile
water for injection or saline may be provided so that the ingredients may be mixed
prior to administration.
[0058] A pharmaceutical pack comprising one or more containers filled with one or more of
the ingredients of the pharmaceutical composition is also contemplated.
[0059] The following examples illustrate the present invention. They are provided by way
of illustration and not for purposes of limitation.
[0061] A soluble CR1 comprising the entire extracellular domain of mature human CR1, obtained
under the product designation TP10 from AVANT Immunotherapeutics, Inc. (Needham, MA),
was used as the test composition in a concentration of 8.3 mg/ml of TP10 in BSS®.
Sterile balanced salt solution (BSS®) was used as a control: BSS® is a sterile physiologically
balanced; salt solution, each mL containing sodium chloride (NaCl) 0.64%, potassium
chloride (KCl) 0.075%, calcium chloride dihydrate (CaCl
2·2H
2O) 0.048%, magnesium chloride hexahydrate (MgCl·6H
2O) 0.03%, sodium acetate trihydrate (CH
3CO
2Na·3H
2O) 0.39%, sodium citrate dihydrate (C
6H
5O
7Na
3·2H
2O) 0.17%, sodium hydroxide and/or hydrochloric acid (to adjust pH) and water for injection.
Alcon Laboratories (Fort Worth, TX) supplies a comprehensive range of ophthalmic surgical
pharmaceutical products, including viscoelastic solutions and intraocular irrigating
solutions including BSS®.
[0062] The efficacy and safety of intravitreal administration of sCR1 following laser-induced
choroidal neovascularization (CNV) was determined as follows. The mice were collected
into two groups of six mice each, control (BSS®) and test (sCR1).
[0063] Male C57B16J mice of approximately 25 g were used. For all laser and examination
procedures, animals were sedated with Avertin® tribromoethanol solution (Winthrop
Laboratories) of 0.02 ml/gm body weight (1.25% w/v tribromoethanol, 0.8% v/v amyl
alcohol). Topical 1% tropicamide and 2.5% phenylephrine were administered for pupillary
dilation. A cover slip was applied to flatten the cornea, as needed.
[0064] The animals were positioned on a Mayo stand before a slit-lamp (Carl Zeiss Meditec,
Jena, Germany). The fundus was visualized using a panfundus corneal contact lens and
goniosol. A red-diode laser delivery system (OcuLight GL, Iris Medical Instrument,
Inc., Mountain View, CA) was used for photocoagulation (532nm wavelength, 0.05 second
duration, 75 µm spot size, and 120 mW power) (
Lambert et al., 2003, Faseb. J., 17(15):2290-2292;
Tobe et al., 1998, Am. J. Pathol., 153(5):1641-1646.). To produce an acute vapor bubble suggestive of Brush's membrane rupture, a 75
µm diameter spot at a moderate laser power of 120 mW was used. A series of four photocoagulation
sites were concentrically placed at equal distances (~75 to 100 µm) around the optic
disk in each eye.
[0065] Within a few minutes after lasering, each animal (n=6 per group) received a 10 µl
intravitreal injection in each of its eyes of either the test compound (in the sCR1
group) or BSS® (in the control group). Both eyes of each animal received the same
injection.
[0066] Two weeks after laser photocoagulation, neovascular development was photographically
documented by color fundus photography (Kowa Genesis fundus camera) and fluorescein
angiography (FA). For FA evaluations, 25% sodium fluorescein (0.1 mg/kg) was administered
intraperitoneally. The size of the laser photocoagulation sites as well as the presence
of subretinal vessels, subretinal hemorrhage, subretinal fluid or subretinal lipid
was noted and recorded. Individual lesion sites, photographed during late phase fluorescein
angiography, were subjected to analysis for the presence and intensity of staining
and leakage using the murine FA leakage score (0 "no leakage" to 3 "strong leakage")
as reported previously by others (
Takahashi et al., 1998, Am. J. Ophthalmol., 126(6):791-797).
[0067] At the conclusion of the experiment, two weeks after the laser, the animals were
euthanized and the eyes enucleated and processed for histological analysis. Serial,
radial tissue sections from each recovered lesion site were evaluated in their entirety
to quantify the extent of fibrovascular proliferation. Histological findings from
different groups were examined and compared to assess: (1) the presence or absence
of neovascularization; (2) the degree of neovascularization with respect to the choroid,
Bruch's membrane, and the retina; (3) the responses of the retinal pigment epithelium
cells to the original injury and subsequent neovascularization; and (4) the inflammatory
response to the original injury and subsequent formation of choroid neovascular membranes
(CNVM).
[0068] For statistical analyses, maximum CNVM thickness measurement, which typically occurred
at or near the center of the initial trauma site, was obtained from digital photographs
(Nikon CoolPix 990 modified camera system) and then converted to µm measurements (using
graticule image measurements for comparison). This technique demonstrated reproducibility
of measurements within ± 2 µm using a random sampling of representative masked lesions.
Mean CNVM thickness values for each group were obtained using the maximum thickness
measurements of the 4 recovered CNVM lesion sites per eye to then determine an average
value for each site within each group.
[0069] The analysis for the presence and intensity of staining and leakage using the murine
FA leakage score are presented in Table 1, with data represented in scale from 0 "no
leakage" to 3 "strong leakage".
[0070]
Table 1 - Murine FA Leakage Score
BSS group score |
1.71 |
sCR1 group score |
1.35 |
p = 0.058 |
[0071] The data obtained from the measurement of the maximum choroid neovascular membranes
(CNVM) area and thickness are presented in Table 2.
[0072]
Table 2
|
|
sCR1 group |
BSS control |
t-test |
Maximum area (µm2) |
per laser site |
8716 ± 3507 |
11,232 ± 4359 |
p = 0.018 |
|
per eye |
8744 ± 2195 |
11,213 ± 1763 |
p = 0.026 |
Maximum thickness (µm) |
per laser site |
55.6 ± 16.6 |
57.6 ± 14.0 |
p = 0.616 |
|
per eye |
55.5 ± 7.0 |
57.8 ± 8.2 |
p = 0.549 |
[0073] The results indicate that sCR1 had a pronounced effect in reducing the choroidal
neovascularization in this animal model of AMD. This is important data tending to
show that inhibition of complement activation is a valid approach to the treatment
of AMD and other diseases and disorders of the eye characterized by undesired neovascularization.
Following the foregoing example, additional therapeutic formulations containing a
complement regulatory protein such as sCR1, Factor H, C4-BP, DAF, and MCP may readily
be tested, prepared and used for the treatment of AMD and related diseases of the
eye characterized by undesired neovascularization.
[0075] A soluble CR1 (sCR1) comprising the entire extracellular domain of mature human CR1,
obtained under the designation TP10 from AVANT Immunotherapeutics, Inc. (Needham,
MA), was used as the test composition in a concentration of 9.1 mg/ml of TP10 in BSS®
prepared from lyophilized TP10. BSS®, commercially available from Alcon Laboratories
(Fort Worth, TX), is a sterile physiologically balanced, salt solution, each mL containing
sodium chloride (NaCl) 0.64%, potassium chloride (KCl) 0.075%, calcium chloride dihydrate
(CaCl
2.2H
2O) 0.048%, magnesium chloride hexahydrate (MgCl
2.6H
2O) 0.03%, sodium acetate trihydrate (CH
3CO
2Na.3H
2O) 0.39%, sodium citrate dihydrate (C
6H
5O
7Na
3.2H
2O) 0.17%, sodium hydroxide and/or hydrochloric acid (to adjust pH) and water for injection.
[0076] BSS® was used as a negative control.
[0077] Triamcinolone acetonide was used as a positive control. Triamcinolone acetonide,
USP, is a glucocorticosteroid with a molecular weight of 434.5, the chemical designation
9-Fluoro-11β,16α,17,21-tetrahydroxypregna-1,4-diene-3,20-dione cyclic 16,17-acetal
with acetone (C
24H
31FO
6), and the following chemical structure:
Triamcinolone acetonide is commercially available, e.g., from Bristol-Myers Squibb
(Kenacort-A; New York). Triamcinolone acetonide has been used in the treatment of
a variety of ocular disorders including AMD, although with the potential for complications
such as transient increase in ocular pressure, cataract progression, and endophthalmitis.
Özkiris et al., 2005, Can. J. Ophthalmol., 40:63-68.
[0078] Brown Norway rats (
Rattus norvegicus) strain BN/SsNHsd, (approx. 120-200 grams; approx. 6-8 weeks of age), were obtained
from Harlan Sprague Dawley, Inc. (Indianapolis, IN).
[0079] The efficacy and safety of both intraocular (IO) administration of sCR1 prior to
laser-induced choroidal neovascularization (CNV) and intraperitoneal (IP) administration
of sCR1 prior to and after laser-induced CNV was determined as follows. The rats were
collected into the groups shown in Table 3.
[0080]
Table 3. Summary of Study Design
Group |
Number of Animals |
Treatment |
Route |
Dose |
Dosing |
1 |
7 |
BSS® |
IO |
10 µL/eye |
Day 0 |
2 |
12 |
sCR1 in buffered mannitol |
IP |
15 mg/kg/d |
Days 0, 1, 2,3,4 |
3 |
10 |
sCR1 (9.1 mg/ml sCR1 in BSS®) |
IO |
10 µL/eye |
Day 0 |
4 |
13 |
Triamcinolone acetonide (40 mg/ml in BSS®) |
IO |
20 µL (0.8) /eye |
Day 0 |
5 |
2 |
none |
NA |
NA |
NA |
[0081] The rats were grouped into four groups of 7-13 male rats each. Two additional rats
were lased, but not treated (Group 5). On Day 0, the rats of Group 3 were dosed intraocularly
(IO) by injection into the vitreous of both eyes of 10 µL/eye of 9.1 mg/ml sCR1 in
BSS®. The rats of the positive control group (Group 4) were also dosed intraocularly
by injection into the vitreous of both eyes with 20 µL/eye of 40 mg/ml Triamcinolone
acetonide in BSS®. As a negative control, the Group 1 rats were dosed intraocularly
on Day 0 by injection into the vitreous of both eyes with 10 µL/eye of BSS®. Starting
on Day 0, the Group 2 rats were dosed once daily for 5 days (Days 0-4) by intraperitoneal
(IP) injection of 15 mg/kg/day of lyophilized sCR1 (in buffered mannitol) reconstituted
in water. After the Day 0 dosing, the retinae of both eyes of each animal were lased.
[0082] For all laser procedures, animals were anesthetized briefly. Tropicamide was administered
for pupillary dilation. A cover slip was applied to flatten the cornea, as needed.
[0083] The retinas were lased using a retinal lasering device (Iridex DioVet laser, wavelength
810 nm) with an attached Kowa PortSlit, SC 14; Keeler fison Indirect Ophthalmoscope
(Lens 30 Diopter). To produce an acute vapor bubble suggestive of Bruch's membrane
rupture, a 75 µm diameter spot at a laser power of 130 mW, 0.1 second duration was
used. A series of three photocoagulation sites were placed at the nine, twelve, and
three o'clock positions, 2-3 disk diameters from the optic nerve in each eye. Rupture
of the Bruch's membrane was identified by bubble formation, which was observed immediately,
at the site of photocoagulation.
[0084] The fundus was photographed (Kowa Small Animal Fundus Camera) at the time of lasing
(before and after) and prior to necropsy. To illuminate the retinal vasculature, animals
were administered sodium, fluorescein (0.1 ml of 10% fluorescein dye) intraperitoneally
about 5 minutes before photography immediately following lasing and prior to necropsy.
[0085] Two weeks after lasing, the animals were deeply anesthetized with CO
2, injected intravenously with 0.1 ml 25% sodium fluorescein intravenously and the
fundus was again photographed. The animals were euthanized and the eyes enucleated
and processed for histological analysis. The left eye of each animal was collected
in Davidson's Fixative (glacial acetic acid, ethyl alcohol, formaldehyde, eosin, and
distilled water), and the right eye of each was collected into Davidson's solution
and changed into 70% ethanol so that the eye could be prepared as a retinal whole
mount to be stained for immunohistochemical stains for neovascularization.
[0086] Fixed tissues for histopathologic examination were dehydrated, embedded in paraffin,
sectioned at 3-5 µm, and stained with hematoxylin and eosin. For histopathology, eyes
were oriented sagitally and then sectioned from the lateral part of the eye through
the retinal-optic nerve region. Digital photographs were made using a 200X objective,
an Olympus 3.3 megapixel Q-Fire digital camera, and Q-Capture software (Quantitative
Imaging Corp.). Perimeters and areas of the neovascular plaque at the burn site were
measured using the program ImageJ 1.30v+, which is available through the National
Institutes of Health. The scale (pixels/mm) was set using a stage micrometer (Graticules
Ltd., Tonbridge, Kent, England) having a 1 mm scale with 100 divisions. A scale of
5.75 pixels/mm was used for the images of the retinal sections. This scale was in
good agreement with previous calibration of the same equipment. In most cases, one
representative section of the burn site was analyzed for each left eye. All measurements
(µm) were entered by hand into an Excel® spreadsheet as the data were obtained. The
mean and standard deviation of the neovascular plaque thickness were determined.
[0087] The data obtained from the measurement of the neovascular plaque thickness are illustrated
in Fig. 1.
[0088]
Table 4
Group |
Number of Animals |
Treatment |
No. Rats with lesions |
Comments |
1 |
7 |
10 µl BSS®, intraocular |
7/7 |
Plaque present in all eyes |
2 |
12 |
sCR1 in buffered mannitol at 15 mg/kg/day for 5 days, intraperitoneal |
7/12 |
Plaque present in 7 of 12, 5 with no lesions observed; mean thickness of the 7 with
plaques was 8.2 ± 2.9 |
3 |
10 |
10 µl sCR1 (9.1 mg/ml sCR1 in BSS®), intraocular |
not determined |
Retinal integrity lost, could not be measured |
4 |
10* |
20 µl Triamcinolone acetonide (40 mg/ml in BSS®), intraocular |
10/10 |
Plaque present in all eyes |
5 |
2 |
None (lasing only) |
2/2 |
Untreated, lased rats |
* three subjects inconclusive and excluded |
[0089] Group 1: Vehicle (IO). Focal areas of neovascular proliferation were present on the retinas of all animals
in the group. The lesion consisted of focal thickening on the surface of the retina
at the optic nerve fiber layer. The thickening was composed of proliferating new vessels.
There was no associated inflammation.
[0090] Group 2: 15 mg/kg/day sCR1 (IP). Small focal areas of neovascular proliferation were present on the retinas of all
animals in the group but were surprisingly less extensive or severe than those seen
in Groups 1, 4 and 5. The lesion consisted of focal thickening on the surface of the
retina at the optic nerve fiber layer. The thickening was composed of proliferating
new vessels. There was no associated inflammation.
[0091] Group 3: 10 µL sCR1 (IO). No neovascular proliferation was discernable in this group. The outer nerve fiber
layer of the retina was compromised. Accumulations of neutrophils and proteinaceous
material was present in the vitreous in 5 of 12 animals. At the time of injection,
it was noted that the test article (TP10 solution) was visible in the vitreous humor
and did not dissipate rapidly. It is likely that the presence of the test article
in the vitreous humor produced gradients in the index of refraction which caused a
diffraction and dispersion of the laser beam leading to extensive damage of the retina.
This effect could be avoided by lasing immediately before intravitreal injection of
the test article.
[0092] Group 4: Triamcinolone (0.8 mg/eye). Focal areas of neovascular proliferation were present on the retinas of all animals
in the group but were less severe than that seen in Group 1 and Group 5. The lesion
consisted of focal thickening on the surface of the retina at the optic nerve fiber
layer. The thickening was composed of proliferating new vessels. There was no associated
inflammation.
[0093] Group 5: Untreated lasered rats. Two rats subjected to lasing, but receiving no treatment in the eye, were also examined.
Focal areas of neovascular proliferation were present on the retinas of all animals
in the group. The lesion consisted of focal thickening on the surface of the retina
at the optic nerve fiber layer. The thickening was composed of proliferating new vessels.
There was no associated inflammation.
[0094] The results indicate that a focal neovascular lesion ("neovascular plaque") is reliably
induced by the lasing procedure. See Fig. 2. The lesion is characterized by a focal
area of vascular leakage at the time of injury as indicated by the fluorescein dye
and fundus photography. There is a residual lesion still present at two weeks. As
shown in Fig. 3, examination of the retina by histopathologic examination by light
microscopy indicates that both Triamcinolone administration intraoccularly, and sCR1
administration intraperitoneally for 5 days, results in pronounced reduction in the
thickness of the neovascular plaque formation, indicating a positive therapeutic effect
for both agents in this animal model of AMD. This is important data tending to show
that inhibition of complement activation is a valid approach to the treatment of AMD
and other diseases and disorders of the eye characterized by undesired neovascularization.
[0095] Intravitreal administration of sCR1 appeared to be associated with damage and loss
to the optic nerve fiber layer of all treated animals, with additional associated
mild inflammation of the vitreous. It is not believed that the dose of sCR1 was injurious
to the retina. Rather, since the sCR1 was administered prior to lasing, the refractive
properties of the sCR1 solution led to dispersion of the laser beam and general internal
damage to the eye. In view of the pronounced positive effect found with the systemic
administration of sCR1, it is believed that intravitreal administration following
the lasing procedure will produce a similarly positive therapeutic effect.
[0096] Following the foregoing description, additional therapeutic formulations containing
a complement regulatory protein such as sCR1, Factor H, C4-BP, DAF, and MCP may readily
be tested, prepared and used for the treatment of AMD and related diseases of the
eye characterized by undesired neovascularization.
SEQUENCE LISTING
[0097]
<110> AVANT IMMUNOTHERAPEUTICS, INC.
<120> Treatment for Age-Related Macular Degeneration and Other Diseases of the Eye
<130> AVA-447.3 PCT
<140> PCT/US07/22276
<141> 2007-10-20
<150> US 60853201
<151> 2006-10-20
<150> US 60928046
<151> 2007-05-07
<160> 3
<170> PatentIn version 3.3
<210> 1
<211> 6117
<212> DNA
<213> Homo sapiens
<400> 1
<210> 2
<211> 1998
<212> PRT
<213> Homo sapiens
<220>
<221> MISC_FEATURE
<222> (1)..(1998)
<223> Full Length Protein
<400> 2
<210> 3
<211> 1931
<212> PRT
<213> Homo sapiens
<220>
<221> MISC_FEATURE
<222> (1)..(1931)
<223> soluble CR1 polypeptide
<400> 3